Transcript Diapositivo 1

From an Affective Disorder to Schizophrenia
– how much affective and how much psychotic?
2015/04/28
Marta Croca; Paulo Martins; Inês Braz; Luís Câmara Pestana
Centro Hospitalar de Lisboa Norte, Lisbon, Portugal
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Introduction
Psychiatric diagnoses:
• Based in operational criteria, defined by general consensus and regularly revised;
• Essential in the process of comunication between mental health professionals,
clinical and epidemiological investigation and to the practice of an evidence-based
medicine;
• Particularly prone to the subjectivity and intersubjectivity.
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Introduction
“(...) it is becoming increasingly clear that we can not distinguish satisfactorily
between these two illnesses (manic depressive insanity and dementia praecox), and
this brings home the suspicion that our formulation of the problem may be
incorrect.”
Kraeplin, 1920
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
Identification: L. D., female, 69 y.o., 9th grade education, retired milliner, widow, two
children, living alone in Lisbon
Family history: Mother with history of Parkinson’s disease; 1st degree cousin with
“Psychosis”
Personal history: Hypothyroidism, medicated with Levotiroxin
Previous personality: anankastic traits (perfeccionism, orderliness, attention to
details)
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
March 1996
(50 y.o.)
• Dysphoric mood, anorexia with 5Kg weight loss, psychomotor inhibition, somatic
complaints (headaches, diarrhea, polyarthralgias) and initial/intermediate insomnia
Life events: husband’s chronic disease (LAS) with a 20-year evolution
• Admitted as an inpatient
- Depressive symptoms remission under i.v. treatment with clomipramine
→ iatrogenic hypomania → remission with neuroleptics
• Prescription at discharge: Thioridazine 25mg o.p.d.; Clomipramine 25mg t.d.s.,
Fluorazepam 15mg o.p.d., Bromazepam t.d.s.
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
November 1998
(52 y.o.)
• After a 2 year period of stability, the patient discontinued the medication
(Paroxetine 20mg)
• 2nd admission to the Psychiatry ward following recurrence of depressive
symptoms
• Admitted diagnosis of Recurrent Depressive Disorder
- Atypical symptoms: anhedonia, hypersomnia, lack of interests and
weight gain
Life events: husband’s death; multiple debts
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
November 1998
(52 y.o.)
1998-2008 (5262 y.o.)
• Regular
Evolutionfollow-up
during
until 2001
admission:
→ affectivesymptom
stability
persistence
under
oral
psychopharmacological therapy with clomipramine 75mg + paroxetine 40mg →
switch to i.v. clomipramine 100mg
• In 2001 the patient abandoned consultations and psychiatric medication (began
being assiduous to catholic gatherings)
History of repeated falls, with multiple fractures (ribs, cranio-encephalic),
since 2000.
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
1998-2008 (5262 y.o.)
• In 2007 → delusional persecutory and mystic ideas (witchcraft); kinesthetic
(genital), visual and accoustic (simple) hallucinations with delusional interpretations
- Trip to Brasil in order to perform “an exorcism” (June 2007)
• In 2008 → brought by her family to a psychiatric consultation
- Periods of sadness and psychomotor inhibition alternating with
periods of more activity and projects. Persistence of kinesthetic
hallucinations, with vespertine worsening.
- Negative evolution in socio-occupational functioning
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
2009
(63 y.o.)
• In June 2009 → fell on the Madrid aeroport (where she had gone to “be
exorcized”), fracturing the left humerus
• Falls interpreted as passivity phenomena by the patient
• Admitted for the 3rd time at the Psychiatry ward in September 2009
• Mini-mental state assessment and clock drawing test were uncompromised.
• Neuropsychological evaluation: mild deficits in orientation, attention and
processing speed, associative memory in the long term, motor initiative, mental
flexibility and non-verbal abstraction capacity
• CT-scan and brain MRI: cerebellar infarction
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
2009
(63 y.o.)
• Iatrogenic hypomania under the association of Duloxetine + Mirtazapine
Diagnostic hypothesis:
• Schizoaffective Disorder, mixed type (depression with atypical
features; debts; high energy and activity periods + psychotic symptoms)
• Mild cognitive deficit (corroborated by neuropsychological and
imagiologic findings)
• Discharged with remission of affective symptoms but persistent psychotic features,
prescribed Quetiapine 400mg od, Lamotrigine 150mg od and Haloperidol 1mg tds
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
2010
(64 y.o.)
Ambulatory consultation
• Mantained regular follow-up in psychiatric consultation
• Extrapiramidal symptoms → switch from haloperidol 3mg to aripiprazole 10mg
• Increasing dynamism of persecutory delusional ideas, with delusional perceptions
and interpretations
- Replaced her apartment’s key locker; instaled a video-camera surveilance
system
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
2011
(65 y.o.)
4th admission at the Psychiatry ward
• Blood tests:
- Lyme’s disease
- Systemic lupus erythematosus (SLE)
- Thyroid function
- Serologies / Syphilis
Lupic anticoagulant +++
Antinuclear antibody +
Anti DNAds +
RA test +
CRF antibodies -
• CT-head scan: diffuse subcortical leukoaraiosis with a predominately pre-frontal
cortical atrophy
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
2011
(65 y.o.)
4th admission at the Psychiatry ward
Neuropsychiatric manifestations of SLE?
Headache (28.3%)
Mood disorders (20.7%)
Cognitive dysfunction (19.7%)
Seizures (9.9%)
Cerebrovascular disease (8.0%).
Psychosis occurs in 10-50% of
patients with SLE and usually coexists
with organic brain syndrome.
Peripheral nervous system.
Organic brain syndrome → most
common severe manifestation of
CNS-SLE; characterised by abrupt or
gradual onset of: Memory
impairment; loss of orientation,
intellect, or judgment; apathy;
irritability; delirium.
(Shaye Kivity 2015)
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
2011
(65 y.o.)
4th admission at the Psychiatry ward
Neuropsychiatric manifestations of SLE?
Magnetic resonance imaging (MRI):
Sensitive,
relatively
available,
exclusion of other neurological
conditions. More than half of
patients diagnosed with NPSLE have a
normal MRI of the brain.
• Brain MRI:
features
without
distinctive
(Shaye Kivity 2015)
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
2011
(65 y.o.)
4th admission at the Psychiatry ward
• Lombossacral MRI: degenerative lesions in L4-L5 without neuromeningeal
compromise
• EMG: no evidence of peripheric lesions (dysesthesia of pelvic pavement)
• Normal PET-scan; neuronal antibodies -; tau-protein and beta 2 amiloyd protein –
• Gynaecological observation: macerated vaginal mucosa (compulsive manipulation
of the genital area)
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
2011
(65 y.o.)
4th admission at the Psychiatry ward
• Persistence of psychotic symptoms: delusional thoughts, kinesthetic hallucinations
with clinophilia during periods of worsening of hallucinatory symptomatology
(which improved with Duloxetine re-introduction)
• Medication at discharge: Clozapine 100mg; Duloxetine 60mg; Diazepam 5mg t.d.s;
Fluorazepam 30mg b.t; Prednisolone 20mg b.d.s
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
2011-2015
(69 y.o.)
Ambulatory consultation
• Follow-up in Rheumatology consultation → ELS hypothesis not confirmed →
discharged from this consultation
• Sustained passivity phenomena, kinesthetic hallucinations, persecutory and mystic
delusions
• Considerable side-effects of clozapine: excessive salivation and ataxia, with
frequent falls → exacerbation of delusional interpretations of passivity phenomena
• Orbicular diskinesia of the eyes
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
2011-2015
(69 y.o.)
Ambulatory consultation
Electroconvulsive therapy from March 2012-2013, with transitory
improvement of the kinesthetic hallucinations
• Accentuation of the behavioural dynamism of the delusional ideas of demonic
possession; endopsychic accoustic hallucinations of a pejorative/sexualized nature
• Egodystonic component of these thoughts, associated with depressed humor
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Case report
History of present illness
February 2015
(69 y.o.)
5th admission in the Psychiatric ward
Diagnostic hypothesis:
1. Schizoaffective disorder, mixed type (bipolar)
- mood episode with psychotic features
2. Chronic hallucinatory psychosis
- strong hallucinatory component with delusional interpretation
3. Affective paraphrenia
- proeminent hallucinations…
4. Late-onset Schizophrenia
- prominent affective symptoms…
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Discussion
Unipolar
depression
Bipolar I
disorder
Schizoaffective
disorder, mixed
type
Late onset
Schizophrenia
“Perhaps what is in-between represents a cross of the underlying dimensions of the
two voluminous spectra, or superposition of some of the contributory factors of one
on the other.”
(H. Akiskal, in The overlap of Affective and Schizophrenic Spectra, 2006 )
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Discussion
Longitudinal diagnostic shifts could translate:
• Natural evolution of the disease
• Symptom modifications due to the use of medication or other substances
• The emergence of previously unknown data
• Excessively simple diagnostic schemes, in regarding the disease’s phenomenological
complexity
From an Affective Disorder to Schizophrenia
- how much affective and how much psychotic?
Discussion
In search of future directions:
• Studies suggest some “mixing” of “psychosis” and “depression genes” (Berettini,
1998; Gershon, 2000)
• It is plausible that “clock genes” could modify the expression of “mood genes” or
“psychosis genes” to lead to seasonal or cyclical rather than chronic or deteriorating
disorders (Bunney and Bunney, 2000)
• Oligogenic threshold of additive broad behavior genes whereby fewer genes would
spell out depression, a great number would fashion bipolarity, and the largest
number would translate into schizophrenic psychosis (Gershon, 2000)
• Temperament genes might moderate the differential expression of affective and
schizophrenic psychopathology (Kelsoe, 2003; Evans et al,2005)
The end!
Thanks for your attention.
2015/04/28
Marta Croca; Paulo Martins; Inês Braz; Luís Câmara Pestana
Centro Hospitalar de Lisboa Norte, Lisbon, Portugal